Healthcare Value Analysis

Tracer Methodology: An Important Infection Control Tool for Identifying Risk

By Sylvia Garcia-Houchins, MBA, RN, CIC

This article originally appeared in the October 2022 issue of Healthcare Hygiene magazine.

Each infection prevention and control program within healthcare organizations across the nation is unique. All infection prevention programs should share similar foundation and structure, but each individual program is shaped by its healthcare organization’s unique culture, physical location(s), and staff. Additionally, each program contains various combinations of care treatment, services, supplies, products, and equipment.

It is the uniqueness and ever-evolving nature of each healthcare organization that validates the importance of periodically using The Joint Commission’s tracer methodology as a diagnostic tool. The tracer methodology is the process that Joint Commission surveyors use to analyze a healthcare organization’s systems or processes for delivering safe, high-quality care. It is used to identify real and potential patient safety risks.

By periodically using tracers, infection preventionists can not only monitor for compliance with set requirements (checklist approach) but can also use a broader review to identify and assess variations in processes and practices. Some variations are completely acceptable, while others are potentially dangerous and could put a healthcare organizations, staff, patients, and visitors at risk.

While using tracer methodology Joint Commission surveyors analyze processes by following an individual patient or resident through the healthcare organization’s care processes in the sequence experienced by that individual. The tracer methodology process may require visiting just one or multiple care settings to review the care rendered and the systems to support that patient’s care. As often witnessed during survey, tracer methodology helps identify varying level of risk – including some that pose an immediate threat to a patient’s health or safety and require immediate action to mitigate the risk.

An infection preventionist can use tracers to identify risks that may have resulted in a patient developing a healthcare-associated infection, to proactively identify risks that could result in an infection, or to review a newly implemented risk-reducing healthcare system.

For example, an infection preventionist could trace a patient with a central venous catheter (central line, trace the care of a patient who developed a central line-related bloodstream infection or trace a system that has been implemented to decrease risk of central line infection.

By tracing the patient’s locations beginning with where the initial decision was made to insert a central line, to the location of insertion, to each location where it is used or accessed, infection preventionists can identify risks that could be acted upon to decrease the risk of central line related bloodstream infection for future patients.

Important aspects of a good tracer process include:
• Invite variety. Do not follow the same tracer path every time
• Always keep an open mind when collecting tracer data
• Ask open ended questions that lead to a follow-up question or create a “show me?” moment
• Collect information that can be further explored– either immediately or when time allows
• Unless someone is at immediate risk, do not immediately begin remedying – the purpose is to collect tracer data
• Do not place blame during tracer processes

To better illustrate the tracer process, consider the basic example of an individual patient tracer utilized to trace a patient with a central line. Tracers can begin anywhere, but for this example scenario we first visit the healthcare facility’s oncology floor to identify a patient with a central line.

Then, we review her medical records. Medical records indicate the patient needed a central line for administration of chemotherapy, and subsequently, she had it inserted in the interventional radiology department. (Patient education is documented by the clinic before the insertion, and by radiology before and after the procedure.) Further tracing shows that the patient’s central line has been accessed at the hospital’s infusion center emergency department, inpatient oncology unit, and general medicine unit as well as the hospital’s off-site infusion center.

Next step, the patient is interviewed. She explains that she was overwhelmed by her diagnosis and depends on her husband to remember what she is supposed to do. She remembers being told that she would need a central line placed for chemotherapy and subsequently had it inserted the next week in Radiology. Placement of a central line was not presented as an option, but as a mandatory step, if a patient is to receive chemotherapy. Staff explained the procedure and directed her not to shower until the insertion site was healed. She was given written instructions at her first chemotherapy visit the following week with direction to look out for redness, swelling, pus, and fever. She was also given direction to call the clinic or an after-hours number to report any problems.

Since the inception of the patient’s treatment, nurses in outpatient chemotherapy used a kit to access the central line but since she was admitted, no kit was available. Similar supplies were used when accessing the central line to administer medications, however the technique varied a bit. The emergency room (ER) nurse used alcohol before carefully accessing the patient’s central line. She drew blood for tests yet seemed very nervous. The patient noted that nurses who accessed her central line usually wear a mask, but few requested the patient also wear a mask.

The patient understands that infection of her central line is a significant risk, and she needs to protect it, however she is unsure of what the nurse who gave her the written instructions meant by directing her to protect her line. When asked to role play what she would do if someone accessed her central line incorrectly, the patient says she assumes that staff know what they are doing, Further, she says she would never question the care provided by a health professional and doesn’t want to be seen as a difficult patient.

When retracing all locations, the patient has visited, we discover that there are two types of central line access kits in use – one kit includes chlorhexidine containing skin preparation and the other includes plain alcohol. Nurses are allowed to choose according to preference, but most use the chlorhexidine product because it is known to better disinfect. We also find that the healthcare facility’s general medicine unit and emergency room do not stock central line access kits. These areas, instead, gather patient supplies as necessary.

Interviews with staff outside of the infusion areas and oncology unit identify varying levels of experience working with central lines and some nurses say they have yet to complete a competency assessment but have been taught by a colleague, key steps of central line access. One of the nurses in the ER says she asks for oncology staff to access a patient’ central line if it looks like that patient will be admitted. Otherwise, the nurse insists that physicians order peripheral blood draws and if necessary, a peripheral IV. Undoubtably, the tracer information collected shows that considerable variation exists regarding central line dressing protocol, depending on the location.

Observations from this tracer example scenario highlight variations in practice, supplies, education, and competency of staff caring for patients with central lines. In this example case, provided patient education failed to achieve its desired objective, since the patient is uncertain of the healthcare organization’s approved process for accessing her central line and does not feel empowered to speak up if staff deviates from the process.
Information from this tracer could be used in multiple ways, including:
• Prioritizing tracer information based on risk and using it to develop an infection prevention and control plan for patients with central lines
• Utilizing tracer information as a starting point for more in-depth study and resolution of an issue Exploring how to improve patient education and empower patients to speak up
• Providing data results to a performance improvement team to plan and implement a rapid- cycle plan to improve supply chain issues
• Analyzing root causes to determine why implemented processes have not been sustained

Opportunities to use tracer information are only limited by the staff member who collects it. Often infection preventionists want to continue to collect more extensive data to prove that an issue is real, however they fail to act, because they want their “data” to be perfect. Occasionally, that approach may be appropriate, but at other times, action immediately needs to be taken.

Using the tracer methodology may move some infection preventionists out of their routine “surveillance” comfort zone. Others recognize it provides opportunity for positive interaction with patients and staff and helps identify risks that might not have been detected though routine surveillance, compliance rounding, or use of checklists. Tracer methodology is one more tool infection preventionists can use to identify risk for infection. It is worth giving tracer methodology a try.

Access more in information about The Joint Commission’s tracer methodology here.

Sylvia Garcia-Houchins, MBA, RN, CIC, is director of infection control and prevention for the Office of Quality and Patient Safety at The Joint Commission.

Occupational Health Contributes High Value to Decision-Making

By Barbara Strain, MA, SM(ASCP), CVAHP

This article originally appeared in the October 2022 issue of Healthcare Hygiene magazine.

During my 41-year tenure in healthcare provider organizations, occupational health was the stalwart that was always there, keeping a vigil-like atmosphere to ensure staff could perform their tasks in a safe environment with no harm. That’s a tall order given the pressures exerted 24 hours a day, 365 days per year in every patient-care setting.

Physicians, nurses, technicians, and assistants working in occupational health must know and understand the job hazards that staff may be exposed to and the work practice controls, protective equipment, and policies to prevent them from causing harm. The list of hazards includes but is not limited to these categories and examples:
- Infections – Hepatitis, HIV, Tuberculosis, Influenza, SARS-Co-V2, etc.
- Needlestick and sharps injuries: Hypodermic, winged, suture, spinal, scalpels
- Blood and body fluids- urine, blood, secretions, vomit
- Back Injuries: Patient movement tasks in bed/stretcher, out of bed/stretcher, in/out of chair, up off the floor, lifting boxes, repetitive motion tasks e.g., folding or stocking linens
- Slips, trips, and falls: Impediments, spills, footwear
- Allergy-inducing substances: Latex, strong odors, soaps, lotions, chemicals, non-woven materials
- Violence: Patient on staff, visitor on staff, staff on staff
- Stress: Staff/patient ratio, overtime, overwhelming morbidity and mortality, violence, hazards
- N95 fit-testing

In addition to keeping up to date with OSHA, FDA, CDC, NIOSH, and other regulatory and guidance agencies, occupational health works closely with infection prevention and control, clinical microbiology, laboratory, and pathology to know the status of what trends are circulating within their organizations and with local and state health departments to an eye to what is potentially emerging. Provider agencies have a list of microorganisms and diagnosed diseases that must be reported to their state public health departments. Be sure to check on the different processes for reporting that may be used depending on where you are geographically.

Occupational health monitors employee’s health by managing symptoms while at work or absences due to sickness, fitness for duty exams, mental well-being assessments and other required needs depending on the type of work in your organization and the experience and licensure of the occupational health staff.
For individuals who have been injured or become ill while working, occupational health assesses the injuries, review the medical documentation the employee’s physician submits to include the amount of time recommended before returning to work. the level of work the employee can manage from light duty assignments to full time in their regular role, and the time frame involved. Workers Compensation programs are state-based, with the claims forms usually filed by occupational health.

Based on my experience, occupational health was an integral part of the institutional safety committee and reported monthly statistics on sharps injuries, slips, trips and falls, blood and body fluid exposures, staff vaccination rates, fit testing, seasonal events, and metrics for monitoring certain emerging conditions.
One of the key operational elements is the ability of occupational health to have a documentation system to include actionable details to assess the need to change products, introduce work practice controls – special gloves, plexiglass barriers, shields on equipment to prevent cuts, or provide training/retraining in the use of products. The data is to be robust enough to know the roles of the individuals harmed, the department or geographical location where the employee was harmed, the part of the body that was harmed, whether finger, eye, foot; what the employee was doing when they were harmed, whether suturing, performing an autopsy, drawing blood. If a product was involved and if possible, list the type, company, product code, lot number and if it was secured for review. This information is invaluable to protecting employees as well as preventing transference of potential diseases/harm to patients such as hepatitis.

Occupational health, infection prevention and control, quality and safety departments use this data to examine trends, potential trends or immediate harm instances to recommend further review and action. Value Analysis is made aware of these actions and begins an investigation using the data provided to “go to Gemba”-the department where the injury occurred- and investigate the details, retrieve any secured products or obtain a good description. If a different product is needed, value analysis looks for comparable but potentially safer versions, organizes evaluations both in the department where the injury occurred but also to any other user departments to assure equality of safety in the organization.

Value analysis involves occupational health and the data they have collected for overall decision-making for initiatives that involve preventing staff injuries. An often-cited example involves selecting and paying for patient movement equipment or products that reduce back and other injuries to clinical staff directly caring for patients or allied health or support staff transferring patients to stretchers or chairs, performing testing in procedure areas or otherwise handling patients. Value analysis uses workers compensation data, hours of work missed, hours of work performed by internal or traveling staff until the injured staff return and all costs associated with these activities. The total outcomes and quality picture must come into view at the time of decision-making as well as following metrics in the post-decision implementation. Occupational health data is critical to the value=quality/cost equation to assess whether the investment generated all the expected outcomes.

Barbara Strain, MA, SM(ASCP), CVAHP, is the strategic board liaison for the Association of Healthcare Value Analysis Professionals (AHVAP).

 

 

Sepsis and the Role of Value Analysis: Products, Practices and Procedures

By James Russell, RN-BC, MBA, CAHVAP

This article originally appeared in the September 2022 issue of Healthcare Hygiene magazine.

In value analysis terms, sepsis is about products, practice, and procedures. A robust value analysis program will provide repeatable workflow tools to analyze and evaluate products, practices, and procedures, used to combat sepsis to ultimately result in objective outcome data that can be referenced when changes are proposed.

Products, Practices, and Procedures
First, let’s define what sepsis is. To be diagnosed with sepsis, you must have a probable or confirmed infection and all the following signs:1
• Change in mental status
• Systolic blood pressure — the first number in a blood pressure reading — less than or equal to 100 millimeters of mercury (mm Hg)
• Respiratory rate higher than or equal to 22 breaths a minute

The key, from a value analysis perspective is the word infection. If an infection can be traced to a product used in a patient’s hospitalization (i.e., a central venous catheter or CVC), the value analysis department can assist in evaluating whether any products, practices, or procedures should be altered. We’ll continue using a CVC as an example of a product related to sepsis, with the understanding that others exist.

Products
If we stay with the CVC example, there are many different CVCs in use in hospitals, from many different suppliers. Some of these catheters come with antibiotic coatings on them, some have antimicrobials or even silver impregnated in the plastic itself. Other CVCs will have pressure transducers connected for hemodynamic monitoring. Some of these catheters will be peripherally inserted yet are still counted as “central” lines. Still other catheters will allow for oximetric monitoring (monitoring oxygenation) or provide access for hemodialysis.

An effective value analysis process will take all these factors (and more) into account, including the evaluation of clinical evidence. There are many platforms used by value analysis professionals to assist in published, evidence-based analyses. One, provides an analysis of the pros and cons to using antimicrobials in CVCs.2 Analyses such as these can help synthesize the published, peer-reviewed literature and may even take cost into account. Sepsis and CVCs are connected by central line-associated bloodstream infections (CLABSIs). There are many resources for healthcare professionals regarding CLABSIs, an excellent starting place is the Center for Disease Control and Prevention (CDC).3 CLABSIs, one of the hospital-acquired conditions (HACs)4 established by the federal government to improve patient safety, can have a mortality rate between 10 percent and 30 percent.5 With these data in mind, the importance of combating CLABSIs, and ultimately sepsis, is clear.
Additionally, other platforms utilized by value analysis can offer unbiased comparisons between different products.6 These tools, and many others, provide the value analysis department the ability to assist clinical departments in making informed decisions regarding the products used by a facility.

Practices
As important as the products that are used in a healthcare facility are, the ways in which they are used, clinical practice, is equally significant and worthy of examination. Value analysis can assist in this as well. Often, determining whether a problem exists in practice vs product is the first step toward a course of action. A facility can have the best products on the market available to clinicians, but if they are used inappropriately or inaccurately, there may be little benefit. In fact, there are even products on the market to help combat these practice issues. For example, “scrubbing the hub” of an IV catheter before accessing it is recognized as an important practice in preventing infections; even The Joint Commission references it.7

Recognizing that clinical practice, and competence can vary, there are companies selling products that attach to IV connectors that can negate the need to scrub the hub, as they contain chemicals (ranging from chlorhexidine gluconate to alcohol) that are in constant contact with the IV connector8 or are used specifically for scrubbing the hub correctly.9
Determining if correct practices are sufficient can require different skills than referenced in the products section. Essential to analyzing practice is what LEAN practitioners call “Going to the Gemba,” or the place where things happen.10 Rather than asking clinicians what they do, watching them do it is far more telling in determining if their practice is optimal. Analyzing practice data can be tricky, as it involves what clinicians actually do, not what they say they do. This potential discrepancy should be handled with care, to prevent hostility or defensiveness, which are destructive to any value analysis project.

Procedures
In combination with products and practices are procedures. An appropriate goal in clinical practice (i.e,, placing a CVC, accessing the CVC, changing the dressing, etc.) is to have purposeful steps to be completed, in order, consistently throughout an institution, regardless of caregiver. A CVC insertion checklist is an example of a guideline that is common practice in CLABSI prevention, where an infection prevention and control department has determined the step-by-step procedure to be used for all CVC insertions. Again, The Joint Commission has weighed in with recommendations and even provides a template. 11

In this section, policies come into play. An institution will have policies, procedures, and perhaps even guidelines and protocols that are all geared to create an environment of consistent care, regardless of a patient’s physical location or their caregiver. Analyzing these written procedures can be instructive and comparing them to the practice outlined above can help the value analysis and clinical departments determine if changes are necessary.

A total package of sepsis prevention can include specific situations, such as CLABSI prevention. Inherent in these situations can be product, practice, and procedure analyses in which value analysis can readily assist. Clinical departments can benefit from collaborating with Value Analysis departments to determine the best methods of providing patient care for the good of the patient, caregiver, and institution. As shown in this article, with the use of central venous catheters as an example, this partnership between clinical departments and value analysis can help an institution enact practices that are evidence-based and analyzed with objective data to provide positive outcomes. A comprehensive objective analysis can help prevent facilities from defaulting to “fixing” problems with new products, when the root cause may involve practice or procedures. Defaulting to simply adding new products can be counterproductive and fail to address what caregivers actually do, or what their policies tell them to do. In short, in projects to combat very real and potentially fatal conditions such as sepsis, a partnership between clinical and value analysis departments can help provide a positive outcome for all concerned.

James Russell, RN-BC, MBA, CVAHP, is director of clinical resource management for MD Anderson Cancer Center.

1. https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214
2. https://app.lumere.com/research/evidenceinsights/831/?group_id=613
3. https://www.cdc.gov/hai/bsi/bsi.html
4. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HAC/Hospital-Acquired-Conditions
5. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/central-line-associated-bloodstream-infections-toolkit-and-monograph/variability-of-surveillance-practices-for-central-lineassociated-bloodstream-infections-and-its-impl/#:~:text=Central%20line%2Dassociated%20bloodstream%20infections%20(CLABSIs)%20are%20health%20care,to%20%242.3%20billion%20a%20year.
6. www.ecri.org/components/TechnologySnapshot/Documents/Catheters%20Vascular%20Hemodialysis%20Central%20Venous.pdf
7. www.jointcommission.org/-/media/tjc/documents/resources/health-services-research/clabsi-toolkit/clabsi_toolkit_tool_3-21_scrub_the_hubpdf.pdf?db=web&hash=79BF0D29BD4AAF13DEC3C3DE5AB90494&hash=79BF0D29BD4AAF13DEC3C3DE5AB90494#:~:text=To%20Scrub%20the%20Hub&text=Don%20clean%20or%20sterile%20gloves,use%20only%20on%20one%20hub
www.jointcommission.org/-/media/tjc/documents/resources/health-services-research/clabsi-toolkit/clabsi_toolkit_tool_3-21_scrub_the_hubpdf.pdf?db=web&hash=79BF0D29BD4AAF13DEC3C3DE5AB90494&hash=79BF0D29BD4AAF13DEC3C3DE5AB90494#:~:text=To%20Scrub%20the%20Hub&text=Don%20clean%20or%20sterile%20gloves,use%20only%20on%20one%20hub.
8. https://www.3m.com/3M/en_US/p/c/b/curos/i/health-care/medical/
9. https://www.medline.com/jump/product/x/Z05-PF46895
10. https://www.lean.org/the-lean-post/articles/how-to-go-to-the-gemba-go-see-ask-why-show-respect/
11. www.jointcommission.org/-/media/tjc/documents/resources/health-services-research/clabsi-toolkit/clabsi_toolkit_tool_3-17_central_line_insertion_checklist_-_templatepdf.pdf?db=web&hash=B8A6C1BBBD9AD6CE5A8B0E798DDF1D67&hash=B8A6C1BBBD9AD6CE5A8B0E798DDF1D67

 

Value Analysis Week Highlights How We Can Improve Healthcare “Together In Value”

By Barbara Strain, MA, CVAHP

This article originally appeared in the August 2022 issue of Healthcare Hygiene magazine.

National Value Analysis Professionals Week was established by the Association of Healthcare Value Analysis Professionals (AHVAP) and occurs annually the third week in July with a celebration to honor the professionals practicing value analysis principals across the healthcare industry. The theme this year and will remain a catalyst for the future is “Together In Value,” which aligned with the VA Week messaging presented by members from each of AHVAP’s four regions -- West, Central, Southeast, and Northeast, and demonstrated how they collaborate internally within their organizations and outside their organizations with suppliers and local community entities. Those stories and what’s ahead for value analysis is summarized here to provide a roadmap for all roles in the healthcare industry.

Building a Resilient Clinically Integrated Supply Chain
This presentation was moderated by Suzanne Smith, AHVAP west region director and presented by Angelique Vuilleumier, supply chain director, and Marcia Morgenthaler, value analysis manager, with Legacy Health. Following an AHVAP webinar on this topic presented in earlier in 2022, Vuilleumier and Morgenthaler provided a current update on how their early work was progressing. A recap of restructuring of Clinical Value Analysis Supply Chain Services consisted of setting up an executive steering committee, using a data rich approach to focus goals, creating action plans and feedback. The key to moving this work forward was using a LEAN A3 New Idea Proposal approach that focused the goals, highlighted ideas, and planning. Targeted communication was key to make this work and gain approval for additional CVA and SC full-time employees (FTEs). By way of a “road show,” one-on-one with the senior vice president, messaging was tailored to match their goals -- e.g., COO operations. Comparing current savings levels in their old structure to what future savings would be with the new structure was compelling. The return on investment (ROI) would be slow but demonstrate increased engagement and patient outcomes, standardized supplies and clinical practice, promote evidence-based decision-making, increased quality systems and standard work through their Lean operations system. When asked what surprised them most, they resoundingly said the levels of participation. A survey of employees who were asked “how satisfied are you with supply chain services” showed an approximate 44 percent improvement, along with FY22 savings and cost avoidance -- showing that their ROI is paying off.

Unlocking Potential: Benefit of a Strategic Partner Council
This presentation was introduced by Terri Nelson, AHVAP central region director and director of value analysis for Mayo Clinic, and presented by Amanda Puls, value analysis manager for Froedert Health, and Chris Reget, corporate accounts director for a medical products manufacturer. The Strategic Partner Council (SPC) was started from a framework of trust versus finger-pointing. Establishing a vision, mission and eight guiding values and reviewing them at each meeting were some of the secrets to the SPC’s success. The council members are selected through an application process based on a wholistic approach focusing on innovation, strength in the community, collaboration, and other qualities not solely associated with top spend. The council was built on each other’s business point of view-understanding of general financial status, overall organizational goals, and value-proposition sharing. Guest speakers such as the vice president of supply chain, as well as financial and clinical leaders are invited to help tell their stories. Building relationships and trust, industry insights, cross-supplier collaborations, process improvement sharing, and listening are accomplishing great outcomes. Puls shared the scorecard used to follow progress attributed to establishing the SPC. Reget added that understanding the provider’s culture and what is important to them builds relationships.

Collaboration Success Among IDNs Using a Combination of Opportunities
This presentation was given by Melanie Stone, system executive director of clinical quality value analysis at WellStar Health, who began by sharing how their value analysis process actually grew during the pandemic by completing the onboarding of a third-party electronic value analysis request tool which helped them keep up with requests and exceeded their 20-21 goals all the while working remotely. She shared stories relating to keeping their patients and staff safe and finding personal protective equipment (PPE) and other in-demand supplies. The first example related during the presentation was the chance encounter at a barbecue with an entertainment industry contact who wanted to help source COVID-related supplies through their supply chain sources which proved to be a great resource. Next was a collaboration with Georgia Tech, with whom they already worked on special projects; together they were able to make much-needed items. The final story shared was about collaborating with four other large IDNs, a group purchasing organization (GPO), and a global distributor on sourcing, which is still ongoing. Stone advised healthcare systems to be judicious, fill a patient population need, involve physicians and clinicians, refocus, and reprioritize.

How to Identify…?
This presentation was moderated by Gloria Graham, AHVAP Northeast Region director and value analysis manager; it was presented by Robin Lane, value management and analysis director for UPMC, Sue Toomey, a value analysis specialist with St. Luke’s University Health Network, and Pete Galliano, senior director at a medical equipment management company. This session explored the signs and symptoms of burnout, identifying self-help steps and describing strategies that leaders can use to help employees deal with stress and burnout – including feeling tired, frequent illnesses, headaches, or pain, and change in appetite or sleep habits. Emotionally, burnout can manifest as a sense of failure, self-doubt, helplessness, feelings of being trapped, detached, feeling alone, and loss of motivation. Behaviorally, burnout can cause individuals to withdraw from responsibilities, procrastinate, or use food, drugs, or alcohol to cope. The presenters shared a variety of wellness tips such as surrounding yourself with positive activities, eating a well-balanced diet, and practicing meditation that focuses on self-care/self-compassion. Managers should ask “What can I do for you?” and understand the resources their organizations provide to support employees and how to find them.

Current and Future State of Value Analysis
This presentation was given by Elizabeth Eisenberg, AHVAP president and director of value analysis for Scripps Health, and Karen Niven, AHVAP president-elect and director of performance groups and value analysis advisory council for Premier. Both provided their insights on value analysis being at the core of quality patient outcomes and overall value. Niven added that value analysis should have a seat at “the table”—including the finance table, the operations table, the infection prevention and control table, the quality, risk management, safety table, as well as the executive table. The pandemic set the stage for recognition and acknowledgement of the importance of a strong value analysis process. Eisenberg stressed that AHVAP is the leading organization that has established the “process for evaluating healthcare services for clinical quality and cost effectiveness” and continues with nimbleness and flexibility to provide education and programs to assure value analysis is promulgated across the healthcare industry “Together in Value.”

Barbara Strain, MA, CVAHP, is strategic board liaison for the Association of Healthcare Value Analysis Professionals (AHVAP).

Making a Case for Reusable Gowns Using a Value Analysis Framework

Barbara Strain, MA, CVAHP, founding member and strategic board liaison of the Association of Healthcare Value Analysis Professionals (AHVAP), reached out to Michael Overcash, PhD, executive officer of the Environmental Genome Initiative, to discuss new evidence to bolster the case for reusable textiles in healthcare.

Overcash, fresh off a presentation of this topic at the recent Symposium on Healthcare Value Analysis & Infection Prevention along with co-presenter with Lynn Sehulster, principal of Environmental Infection Prevention, LLC, has presented webinars for AHVAP in the past about this topic. Overcash approaches his work using research, data and analytics in a way that effectively resonates with infection preventionists, quality and risk management leaders, and executive decision-makers while informing the value analysis process. To demonstrate how value analysis might approach an initiative to adopt reusable healthcare textiles beyond the most recent temporary solution during times of non-woven product disruption this article is being written in the form of a value analysis decision-making process template to be used by any healthcare organization.

Step 1: Identifying a need

Two supply chain incidences occurred early in 2020; one pandemic-related; one pandemic-adjacent. By January 2020 a recall of sterile disposable surgical gowns was communicated to healthcare end-users based on an identified sterility assurance issue in both single packaged gowns and those found in the manufacturer’s custom packs.1 This, coupled with a soon to be depletion of raw materials to produce enough disposable surgical and isolation gowns needed to provide safe and effective protection to staff and patients as a result of overwhelming use at the height of the COVID-19 pandemic, resulted in a return to use of reusable textiles for these gown types. Based on this need, your organization should pursue an initiative to review its overall financial, sustainability and safety experience to determine the potential use of reusable textiles as the primary source of protection as a risk-mitigation strategy to control our own supply chain and outcomes.

Step 2: Collect and review clinical based evidence

Using the information from peer-reviewed articles that Overcash published, co-published or reviewed, provides the most compelling data to the most common reluctance to return to reusable textiles- do they pose a health risk. To debunk this long-standing ideology, he and Sehulster submitted a letter to the editor of Infection Control & Hospital Epidemiology which was published in July 2021 where they compared the 50-year publication record (1970-2020) of hospital-acquired infections (HAIs) in the U.S. and UK related to healthcare textiles (HCTs) to the overall actual occurrence of HAIs in hospitals in the same time. 2 They found 69 HAIs attributable to laundered HCTs and highly speculated that “the infections related to reusables may be underreported,” and so used a factor of 100 times would allow them to do a reasonable yet conservative risk analysis which equated to 6,900 HAI cases in past 50 years or about .37 cases/day in the U.S. and UK.  The estimated actual total number of HAIs is 5,500 cases/day in this 50-year period; and so, in probability terms the chance of a patient having an HAI linked to contact with laundered, reusable textiles is about 1 in 14,900. The paper put that rate into perspective by explaining the odds of a person in the U.S. and the UK over a 78.5-year lifespan being struck by a meteor is 1 in 9,000.

The Association for the Advancement of Medical Instrumentation (AAMI) and ANSI-American national Standards Institute have established standards to quantify the liquid-barrier performance of isolation gowns and other medical textiles.3 The Centers for Disease Control and Prevention (CDC) states that “Through a combination of soil removal, pathogen removal, and pathogen inactivation, contaminated laundry can be rendered hygienically clean. Hygienically clean laundry carries negligible risk to health-care workers and patients, provided that the clean textiles, fabric, and clothing are not inadvertently contaminated before use.”4

Step 3: Data and analytics

Data comparing disposable surgical and isolation gowns to reusables is based on multiple characteristics that must be considered to assure a fully formed decision can be reached.

The list of key characteristics based on annual usage include but is not limited to:

Table 1:  Key Data Characteristics for decision-making

Disposable Data points Reusable Data Points
Quantity of disposable gowns used Cost of initial order of reusable gowns and subsequent replacement of “ragged out” unusable gowns

 

Cost of each disposable gown purchased Conversion use factor:  # of disposables gowns/ each reusable gown.

Isolation gowns 1:60 disposables

Surgical gowns   1:75 disposables

Pounds of disposable gowns disposed Laundering costs

(in-house or outsourced models)

Cost/pound of waste disposable through to the end of life Sterilization if required e.g., surgical gowns, certain patient populations
Environmental impact of manufacturing process, packaging, shipping, end-of-life disposal related to energy and fossil resources, global warming, etc.

See Table 2 for categories and savings %

Environmental impact of textile production, laundry, end of life disposal, reduction in solid waste generation, Blue Water consumption, global warming, etc.

See Table 2 for categories and savings %

 

 

Table 2:  Environment indicator calculations from of life cycle inventory components for reusable vs. disposable systems for isolation gowns3

  Natural

Resource

Energy, MJ/1,000 uses

Global

Warming Potential kg/C02 eq/1,000 uses

Blue Water kg/1,000 uses Solid Waste

at hospital uses

kg/1,000 uses

Life Cycle Inventory Component R D R D R D R D
Gown and packaging manufacture & delivery  
Manufacture &

delivery of gown

1,133 4,996 68.6 300 35.1 74.6 - -
Manufacture &

delivery of packaging

16.7 120 1.03 6.95     - -
End-of-Life landfill  
Landfill isolation

gowns & packaging

2.43 34.9 .139 1.99 0 0 .413-4.41 63.2
Landfill of

biological waste

-.0114 -.0682 .0132 .794 0 0 0-.00323 .194
Laundry Operations  
Laundry 2.538 - 146 - 8.71 - - -
Water for laundry 7.31 - .411 - 0 - - -
Wastewater treatment to restore water 14.4 - 2.08 - 0 - - -
TOTAL 3,712 5,150 218 310 43.8 74.6 .0412-4.42 63.4
Reduction from selecting reusable system, % of disposable system 28% - 30% - 41% - 93-96% -

R=Reusable; D=Disposable; MJ=megajoules

 

When performing analysis all costs including environmental impact should to be considered in final savings calculations.

In the instance that your organization has limited or no use of reusable gowns, you may opt to schedule with a reusables provider a limited evaluation (usage, environmental benefits, and annual cost) of the reusable gown and processes associated with changes that would occur upon implementation of an approval decision.

Step 4: Discussion and decision

Value analysis creates an executive summary of the findings in steps 1-3 and Tables 1-2, process feedback from evaluations, other end-user feedback, and overall savings to present to a multi-disciplinary ad hoc team (MDAHT) composed of infection prevention and control, nursing, supply chain, linen services, environmental services, quality, risk management, safety, and key executive leaders for discussion and organizational decision making.  The process can be enhanced by a decision chart using weighted criteria to assess the pros and cons with a scorecard to provide an objective decision.

Step 5: Implementation and monitoring

Based on an approval decision value analysis assists in implementation planning to assure effective transition, collaborate on education and training, assure resulting contracts contain key performance indicators and metrics agreed upon by the MDAHT. Once the implementation has taken place value analysis continues to monitor and assist in mitigating urgent issues and gathers metrics at specified internal to assure goals are being met.

Overcash emphasizes three critical considerations to keep in mind during the selection process:

- Health risk

- Environmental sustainability

- Annual costs

Editor’s note: Through Aug. 31, 2022 you can sign-in to hear Overcash and Sehulster discuss “Healthcare Textiles and Laundry Related Imperatives” and other real-world infection prevention, environmental services and value analysis healthcare topics from the Symposium on Healthcare Value Analysis & Infection Prevention brought to you by Healthcare Hygiene magazine, the Association of Healthcare Value Analysis Professionals (AHVAP), The Pearce Foundation for Scientific Endeavor, and the Environmental Services Optimization Playbook (EvSOP) Project, who partnered to develop this free virtual symposium that offers 6 contact hours of nursing continuing education. To RSVP, visit: https://inevent.com/en/KeystoneMediaInc/SymposiumonHealthcareValueAnalysisIInfectionPreven/form.php

 

References:

  1. https://www.fda.gov/news-events/press-announcements/statement-quality-issues-certain-cardinal-health-surgical-gowns-and-packs
  2. https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/estimated-incidence-rate-of-healthcareassociated-infections-hais-linked-to-laundered-reusable-healthcare-textiles-hcts-in-the-united-states-and-united-kingdom-over-a-50year-period-do-the-data-support-the-efficacy-of-approved-laundry-practices/93253E00A94CEE5E17FE086AB2AEF3BC#
  3. https://www.sciencedirect.com/science/article/pii/S0196655318300750
  4. https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/laundry.html

Hygiene and Respiratory Care Services: A Survey of Care During the COVID Pandemic

By Garry Kauffman, RRT, FAARC, MPA, FACHE

This column originally appeared in the June 2022 issue of Healthcare Hygiene magazine.

As a career-long respiratory therapist (RT) turned healthcare consultant, I speak with RT leaders daily. The themes that resonate in these conversations are safety and efficacy. RTs think both about patient safety as well as safety for clinicians. Efficacy goes hand in hand with safety, in that it’s critically important that respiratory care services are delivered according to the best available evidence. In my experience, delivering services with scientifically validated devices, supplies, and capital equipment provides not only the best outcomes for the patient but does so with the highest degree of safety.

Throughout the pandemic, access to devices was a significant barrier, particularly for those devices manufactured outside of North America. Many RT departments were forced to “use whatever they could get their hands on,” as one RT director stated. While access seems to have subsided, RT leaders need to reassess the changes they made during the most challenging times to ensure that the devices they are currently using are those that have been validated and not just because they have the lowest acquisition cost. I use this quote from Warren Buffett, who while not an RT, reminds all of us that what we pay up front doesn’t reflect value: “Price is what you pay; value is what you get.”

The following are individual responses to questions received from RT leaders representing different hospital sizes and types from across the U.S:

Question 1: What impact did the pandemic have on your respiratory care services regarding hygiene/safety?
• Policies and procedures were modified in several areas. Interventions that historically were limited to the intensive care unit (ICU) were allowed in other areas of the institution. Personal protective equipment (PPE) was allocated, mandatory precautions were established, and we established an AGP list to enhance safe practice.
• During the pandemic, use of hand hygiene, and the appropriate PPE, became an even greater focus not only for safety, but initially for fear of survival.
• Created an early and acute focus on personal protection and availability of PPE, in addition to an active awareness of our interventions that may increase risk.
• The pandemic touched nearly every aspect of our operations, as keeping a safe and healthy workforce is essential to sustaining our patient care capabilities. There were lengthy isolation and quarantine periods that affected staffing, particularly in the early waves while COVID testing was in its infancy. Looking back, ability to staff safely was probably the most substantial concern, and in addition we’ve had to deal with ongoing losses and vacancies as the pandemic has continued.
• PPE supplies were limited early on which was a concern to achieve the workforce protection goal, as were items we use where demand soared such as filters for various new applications.
• There were not enough rooms with doors and negative pressure rooms especially early on, and higher oxygen and respiratory support needs affected where a patient could be placed.
• While we were struggling with necessary practice modifications for hygiene and safety, there was the ever-present risk from anyone unmasked who coughed and could generate a far higher expiratory flow with dispersion risk. Since one doesn’t always know who is infectious and can be an asymptomatic carrier, it is like the advent of universal precautions earlier in my career for bloodborne pathogens. With respiratory pathogens, getting patients and visitors to also wear masks was something new in the hospital to try to mitigate this risk.
• Infection control, hygiene, and safety are always a paramount when providing respiratory care. The pandemic served as a reminder to staff and helped solidify our practices. Due to the pandemic the department was compelled to be more proactive increasing access to PPE prior to the therapist reporting to their assigned patient care area. Prior to the pandemic, therapists would have just obtained PPE in the patient care areas.
• We certainly found ourselves becoming the bedside experts on enhanced airborne precautions and aerosol-generating procedures. Often before non-respiratory therapy staff would check the plethora of available resources, they would ask an RT. When half-face respirators came into the market, RTs were seeking to learn more about them and asking if they would become part of our PPE arsenal. They were quick to adopt this new PPE option and asked questions regarding filtration of exhaled particles, etc.

Question 2: Which procedures/services did you modify because of the pandemic?
• We had to balance between optimizing patient outcomes and maintaining staff safety.
• We modified almost every service we delivered. Services where there as a potential risk for production of fugitive aerosols were eliminated or conducted under the strictest of protocols. These procedures/services included but were not limited to, bronchoscopies, tracheostomies, sputum inductions, intubation process during codes, aerosol medication delivery, noninvasive ventilation, heated high flow nasal cannula use, open suction, and intubations in the ICU and emergency room.
• When inhalers were in short supply, we developed an interdisciplinary plan with pharmacy, nursing, and infection prevention and control colleagues to temporarily implement a common cannister protocol not previously utilized.
• From an outpatient standpoint, we began to utilize telemedicine technology and home monitoring with our cystic fibrosis patients. We initiated weekly telemedicine calls with these patients to track daily CPT and medication therapy. Through these efforts, therapy compliance increased, and we were able to improve quality without having to risk bringing them into the inpatient setting thus allowing us to minimize their risk of infection.

Question 3: Regarding nebulizers and inhalers (MDI), which do you believe is 1.) more effective and 2.) safer? And why?
• All patients that were ordered on aerosolized therapy were first assessed for MDI use. If not able to perform MDI appropriately, they were placed on The BAN nebulizer in patient activated mode with an expiratory filter in place. This minimized staff exposure.
• We switched rapidly to metered dose inhaler use for non-vented patients. The reason for the change was not due to effectiveness, but for the saving staff time during the administration, distance, and minimization of fugitive aerosols in any area. Any patient receiving aerosol therapy due to inability to coordinate use of an MDI, was placed in a negative pressure room.
• The most effective aerosol-generating device is the one that maximizes medication deposition within targeted airways. Patient characteristics are paramount.
• The variability among key performance characteristics between different types and brands of nebulizers is striking. When nebulizers come up in clinical discussions, it is often without any understanding of the importance of these variables, or even how the device in use in a particular situation stacks up. There is a difference between nominal dose by weight put in the nebulizer reservoir and amount of drug emitted, respirable mass fraction which is affected predominantly by particle size, and nebulizer design.
• Standard jet nebulizers or updraft designs waste a lot of the starting dose of medication and ‘treat the environment’ as much or more than the patient. There are ways to try to capture escaping aerosol with valves and filters in different products or added on, but source reduction when possible is the most effective strategy. With COVID risk, nebulizer safety also depends on device selection. With standard jet nebulizers and co-mingling of inspiratory and expiratory gas streams there is more aerosol generation and dispersion in the environment during the expiratory phase, which can include greater dispersion risk of bioaerosols. Breath-actuated design is ideal for source reduction of fugitive medical aerosols, as well as therapeutic efficacy in other key areas.
• When properly performed with a valved holding chamber, an inhaler is effective by providing delivery of aerosols in the therapeutic range. Therapy can also be provided in less time which is always beneficial during a staffing crisis/pandemic. However, in patients that were in severe respiratory distress and unable to use proper technique, the better option is the nebulizer.
• Regarding these devices, the option that is most effective for the patient, and the one they will be most compliant with, is the most effective.
Question 4: Were Infection Control/Prevention professionals engaged regarding procedure/device changes?
• We had daily huddles with our infection control team, medical director, and administration daily to discuss revision in practices and policies.
• Infection control played a vital role in our administrative covid 19 task force, meetings were conducted daily, and in some cases, several times a day to discuss and make adjustments to our action plans based on the most current recommendations.
• Yes. We very much appreciate their support and trust in us as we collegially have navigated these uncharted waters together.
• Infection control was great about keeping staff updated on the latest information related to the pandemic. They were able to visit various patient care areas and alleviate stress and concerns of staff about our PPE utilization.
• Absolutely. Our infection preventionists were tireless partners and advocates. They were incredibly collaborative throughout the entire COVID-19 pandemic. They were quick to pull in a variety of interdisciplinary content experts to ensure we were making the safest decisions possible at the time.

Question 5: Regarding the changes you made, what impact did they have or were influenced by availability, cost, product quality, RT labor, or documented outcomes?
• With disruption in supply availability, we had to adapt to a variety of products outside of our normal use
• With respect to quality and outcomes, our aerosol delivery device selections must be evidence-based and backed by the largest pool of laboratory and clinical literature available in the industry. Our contributions as RTs are our specialized knowledge.
• Cost did not factor into decisions that I was a part of and not a driving factor from higher levels of leadership within the organization. There was a real focus on doing what was right. Availability of product and product quality became major factors in decision-making activities. We were able to maintain our commitment to utilizing high-quality products, but that often meant that we needed to delay acquisition, stockpile supplies, and be judicious in usage.

Question 6: As a result of monitoring these changes, did you make any changes to the new process? If so, what changes did you make? Do you foresee these changes being permanent or have you resumed previous protocols with non-Covid patients?
• Any changes made to processes during the pandemic have continued to be used. Our goal is to always provide the best care for our patients. We made changes partially to necessity, but also in the best interest for the patients. We will continue to always look for new opportunities to provide the best quality of care for our patients so there will be opportunities for us to modify protocols and therapy in the future.
• It appears many of our previous protocols have resumed, but as a collective team, we are much more willing to challenge the norms and plan for a future that looks different than it did pre-COVID.

In summary, the pandemic posed both a serious challenge as well as an opportunity for RTs to reexamine respiratory care practice. Clinical services, including oxygen therapy, medicated aerosol delivery, lung expansion/secretion clearance, pulmonary function testing, and mechanical ventilation were all impacted. While RTs have always embraced hygiene and safety, I believe that RTs have been more fully engaged with their fellow professionals to ensure that the services they provide are both evidence-based as well as safe for clinicians and patients.

Garry Kauffman, RRT, FAARC, MPA, FACHE, is principal of Kauffman Consulting and is a member and active participant of various committees for the Association of Healthcare Value Analysis Professionals (AHVAP).

Value Analysis Manages a Hand Hygiene Conversion with the Development of a Conversion Toolkit

By Kimberly Miner, RN, MSN, MHA

This column originally appeared in the May 2022 issue of Healthcare Hygiene magazine.

The COVID-19 pandemic has significantly impacted the global healthcare environment. Healthcare organizations continue to face a variety of economic challenges related to supply disruptions that impact the ability to provide patient care. Given the dynamic and complex state of the current healthcare environment it has become vital to standardize clinical commodity products to minimize supply disruptions.

During the COVID-19 pandemic all healthcare organizations were challenged with the ability to procure hand sanitizer products. Healthcare organizations resorted to refilling bottles, purchasing any available product, or even manufacturing their own hand sanitizer to prevent a disruption in patient care. Although suppliers have been able to ramp up production to meet current demand it is important to act on the lessons learned during the pandemic to position ourselves better for future disruptions.

One valuable lesson learned from the pandemic includes standardizing clinical commodity products. Standardizing hand sanitizer products within an organization can prevent supply disruptions by increasing allocation levels with suppliers, allow the internal movement of inventory when supply is tight, and reduce the logistical management of multiple products. Although a simple concept, the process of standardizing hand hygiene products within an organization can be complex and challenging to manage. Hand sanitizer products must adhere to standards and specifications related to alcohol content, require equipment, and installation of dispensers.

After completing a major hand sanitizer conversion across a large healthcare organization, these challenges were recognized, and a hand sanitizer conversion toolkit was developed. This conversion toolkit assists to mitigate the challenges and reduce the complexity for any size healthcare organization.

The value analysis process was implemented in the design of the hand sanitizer conversion toolkit and began with the validation of the chosen formulary product. The selection of formulary products involved close collaboration with the infection prevention and control (IP&C) team, occupational health services and a team of dermatologists who advise the Skin Safe Program. The Skin Safe Program works to identify and recommend the safest products that come into contact with staff and patient skin. After product validation and recommendation for the formulary product list was complete, the next step was to operationalize the conversion to standardize. The operationalization phase of the conversion is where the complexity begins, especially in a large healthcare organization.

Recognizing the complexity and challenges of this type of conversion led to the development of the hand sanitizer conversion toolkit. The toolkit identifies five main phases and breaks each phase down into actionable steps. Each phase of the conversion is organized into a detailed checklist format. The toolkit also identifies required and optional steps and highlights key considerations for a successful conversion. Overall, the toolkit outlines the conversion process and provides all the information needed to prepare end users. It also assists to identify key stakeholders that need to be involved in each stage of the conversion/implementation process as this type of conversion requires a collaborative approach.

The standardization of hand sanitizer products across the Mayo Enterprise presented a variety of positive outcomes. The initial outcome was the elimination of a custom hand sanitizer bottle that was being manufactured to fit into wall and bed brackets. Following standardization, the number of hand sanitizer products purchased across the Enterprise was reduced by more than 70 percent. This reduction has had significant impact in the amount of time staff have dedicated to logistically manage hand hygiene products as well as capitalizes on the limited physical space needed to store these products at the warehouse. Standardization also provides a consistent supply of products to ensure access and visibility of hand hygiene products for clinicians, patients, and visitors. The development of the toolkit led to successful outcomes after conversion. This conversion toolkit can be scaled and reformatted for other conversion activities.

In conclusion, the COVID-19 pandemic has impacted the global healthcare environment and has created economic struggles for all healthcare organizations. The demand of hand sanitizer products increased enormously during the pandemic which created a supply shortage issue around the world. Over time, suppliers have been able to ramp up production to meet the current demand, but supply shortages are likely to be long lasting.

Although the supply of hand sanitizer products has stabilized the delivery of healthcare products relies on a variety of factors including raw material, labor, and logistical management of materials. Healthcare organizations have learned a variety of lessons throughout the COVID-19 pandemic. Standardizing clinical commodity products using a conversion toolkit is a valuable way to position healthcare organizations for success in navigating supply shortages and outages in the future.

Kimberly Miner, RN, MSN, MHA, works in supply chain management for Mayo Clinic.

 

Moving the SPD During a Pandemic: Keeping Value Analysis Dialed In

This column originally appeared in the April 2022 issue of Healthcare Hygiene magazine.

Barbara Strain, founding member and strategic board liaison of the Association of Healthcare Value Analysis Professionals (AHVAP), caught up with Gloria Graham, DNP, RN, CVAHP, clinical value analyst for Cincinnati Children’s Hospital and AHVAP past president, to ask her about the opening of a new critical care tower and the move of their entire sterile processing department to a new expanded space.

Barbara Strain (BS): What was the impetus for moving SPD?

Gloria Graham (GG): No surprise to the readers but the sterile processing department (SPD) was in the basement of an existing building which served all operating room (OR) cases at base campus. Like other hospitals and healthcare systems, the need for expanded or new services was realized over the past 10 years which necessitated renovations or net new space construction; Cincinnati Children’s was no stranger to these phenomena. Our need for critical-care beds and cardiothoracic procedure rooms was growing, as well as new services for high-risk fetal care deliveries and eventually for mothers with potential high-risk pregnancies presented the opportunity to build an SPD to support the new efforts as well as service all OR needs. Plans including a connector from the new critical care tower to the existing building with the remaining operating rooms and expanding the SPD footprint to accommodate the latest technology and practices have been several years in the making.

BS: Describe the process steps that kicked off identification of the supply needs for the new SPD?

GG: A gap analysis between the supplies used in the current SPD space and those that would be required in the new space was key. We started with a purchase history report for an agreed upon time frame for the current SPD and assembled a team of internal subject matter experts consisting of a supply chain sourcing specialist, co-chair of the OR value analysis team, base hospital clinical value analyst and SPD leaders to review. One of the overarching criteria for the review was to clean up the list based on low-use or never-used supplies and supplies for equipment that would no longer be in use post-move. The review group found that the list contained some of the same or similar products from a variety of manufacturers and agreed that one of the key goals was to standardize and reduce variation through this process. Once the list was reviewed a report was generated for all locations that may be using any of the supplies that were suggested to be deleted as well as those that were to continue to be used.

BS: You must have found some aha and win-win moments during this process.

GG: There were many learnings using a process like this. We found some departments in and outside of the base hospital and at our neighborhood locations were using some of these products. We reached out to them to describe the process we were going through and made standardization recommendations where possible. One great opportunity that emerged through this process was the discovery of the root cause of issues related to dry bioburden when scopes were returned to SPD for cleaning and processing. A process improvement project was conducted to look at key steps in the process to determine why this was occurring. Even though the same brand spray was used, when the outside locations used the spray immediately as directed, the scopes would sit for long periods of time before a courier picked up them up. Depending on which end of the courier route, the scopes may continue to sit for an even longer period before reaching SPD at the Base hospital for processing. The optimal process occurred for scopes used at the Base hospital where the interval the scopes sat post spray was short before arriving in SPD for complete processing. Upon discovery of this difference, value analysis assisted in finding a new spray for the outlying areas that was put through a test of change; one of the use areas the furthest away from the base hospital was chosen to try the spray and put through the usual courier process. They saw an immediate improvement with the scopes remaining wet upon arrival at the base hospital SPD. Another outcome of this project was using up of the existing spray prior to converting to the new spray in all areas to reduce waste and costs. The neighborhood locations converted first where the issue needed to be resolved quickly. The base and “liberty” location, which also had their own SPD area, used up the existing spray before converting to the new enzymatic spray.
Overall, this not only improved the care of the scopes but resulted in decreased time SPD had in cleaning the dried-out scopes and gained more time on value added work.

BS: What was the process for net new supply requests?

GG: Designing a brand-new space to meet many current needs while assuring new practices would be accommodated for upgraded or new equipment were built into the construction planning process. This required new indicators, control materials, wraps, tray liners, etc. to accommodate the newer technology and space considerations but how to request these new products to assure availability was the next learning opportunity. The OR value analysis team has representatives from the service lines within the OR which includes SPD. Through a collaboration with the equipment and standards value analysis committee which is the over-arching value analysis process for the other care delivery areas, a clinical value analyst representative attends the OR team meetings and conversely, the OR VA chair attends the E&S VA meetings. This is primarily done for patient safety risk mitigation so all clinical areas who may care for post-surgical patients admitted to their nursing unit know how to care for devices and equipment that accompany the patient as well as common nursing products the OR might also stock. The OR VA team enters new supply requests including SPD into the value analysis technology platform but in the case of the new construction the process was best coordinated by SPD to assure timeliness and practice accuracy. Additionally, some of the SPD leadership was new to their roles so value analysis conducted training and helped SPD in completing the new item request form.

BS: Most of these later activities occurred during the COVID pandemic, what affect did this have on the SPD move?

GG: One thing in our favor was working with most of our current SPD suppliers since most of the equipment were upgrades of current equipment. We each knew each other’s purchasing processes, delivery schedules and representatives. The thing not in our favor were the continued supply chain disruptions for delivery of the new equipment and required different supplies. Value analysis coordination to review appropriate options, check on status of delivery and work through issues occurred when the need arose and continues today.

BS: What one key factor sticks out in your mind that has changed the way value analysis works within your organization?

GG: What we have experienced during the past two years and how we all pitched in to assure patients had the best care and our staff was safe has brought about a new appreciation for all we do. We learned it’s more than the cost of a product that counted but how to convert to substitute products without being wasteful, to exhaust stock of current products when safety is not compromised, and to know how hard it is to find and get supplies. The staff has been tremendous in stepping up in times of crisis with supply disruptions demonstrating our passion of pursing our potential together working as one Cincinnati Children’s. Our experience is not isolated to our organization but has been acknowledged by colleagues around the country – I like to call it “flexible understanding.”

 

Value Analysis Keeps an Eye on Surgical Site Infection Prevention

By Barbara Strain, AM, SM(ASCP), CVAHP

This column originally appeared in the March 2022 issue of Healthcare Hygiene magazine.

The Centers for Disease Control and Prevention (CDC) published a report last year that found healthcare-associated infections (HAIs) increased significantly in 2020.1 This was emphasized by a paper in The New England Journal of Medicine that cited studies on impact of patient safety and infection control by the pandemic.2

An all-hands-on-deck approach in the early high surge was accompanied by successive surges of high acuity and sheer numbers of patients which stressed the staffing infrastructure, compounded the already-busy daily routines of infection preventionists, and required the pivot to alternate PPE, raw materials to make disinfectant wipes, and other decisions that could disrupt the pre-COVID infrastructure.

In contrast to these negative findings that found HAIs increasing in the face of steady efforts that lowered these quality indicators from 2015 baselines the refreshing news is the processes, policies, practices, and products that were implemented worked. While the full impact of SARS-CoV-2 on HAIs is not yet fully known, the quarterly surveillance during of the pandemic was affected by the implementation of the extraordinary circumstance exception policy by the Centers for Medicare & Medicaid Services (CMS) which excused facilities from HAI surveillance and reporting.3 Despite the ECE policy, up to 88 percent of acute-care hospitals reported results for some HAIs as a category but a larger number did not report in the SSI category. Caution is to be heeded in interpreting HAI data starting in 2020.

Value analysis is a proven process that relies on a) clinical-based evidence, data collection - electronic medical record, surgical records, purchasing, finance, infection control measures, quality, safety, risk management- b) synthesizing analytics, c) preparing executive summaries for decision making and d) if approved participates in successful implementation and e) monitors results to assure the decision proved out. Value analysis professionals are the frontline, risk-avoidance watchman using what is the equivalent of a giant checklist.

When considering whether new or current products or services will not adversely affect HAIs (CLABSI, CAUTI, VAP) or healthcare-acquired conditions (HACs), falls, or HAPI, one can appreciate how products may directly affect these outcomes. From antibiotic-coated central line catheters, packaging to standardize insertion, dressing change kits, yellow gowns and alert signage, therapeutic support surfaces, lift equipment as tangible mitigation tactics. SSI rates are in their own category. For example, during 2020, 2021 and early in 2022, SSI-rate accuracy was compounded by the overall decrease in surgical procedures then rollercoaster efforts to relieve the case backlog.

The complexity involved in acquiring surgical site infections (SSIs) is multifactorial; human, physical, environmental, instrument processing, policies, programs, and compliance (e.g., SCIP-Surgical Care Improvement Project), antibiotic stewardship, basic infection prevention interventions such as hand hygiene, and the list continues.4
In 2019 the CDC reported there were 157,000 annual SSIs and 1 million added patient days at an estimated cost to the healthcare industry of $3.38 billion. They believe half of the patient days are preventable.5

When reviewing specifications of products or services, value analysis assures that suppliers are asked, “Will your solution have an impact on our HAI, HAC or other quality indicators?’ If they say yes, they are required to submit peer-reviewed literature, reference provider end user organization contacts, along with internal science development. In some instances, the product or service is so new that peer-reviewed literature may not exist. If an organization finds still finds merit in a product or service, it may decide to do a study or evaluation to collect information to support making an informed decision.
For products in the operative environment, it is more complex; onboarding one product or service may disrupt a practice that has already resolved one of the conditions related to acquiring an SSI. An example is equipment that produce that effect the operating room (OR) environment by changing air flow or creating temperature imbalances or cannot be accommodated safely in the space and may create a hazard.

In addition to the OR director, service line nurse managers, surgeon champions, and anesthesia perioperative value analysis teams should include a director or manager from the sterile processing department (SPD). Decisions for processing equipment, detergents, high-level disinfection agents, prep and pack materials like instrument pouches and quality control process check materials should be discussed by the team.

One state patient safety advisory stated “…there is evidence of infection transmission when cleaning and sterilization procedures have not been adhered to, or where quality control has been poor…”6 Surgical instruments and procedures have become more complex, with torturous paths, moving parts and other nooks and crannies where bone, tissue and blood can get trapped, it’s important to have the SPD voice at the table.7

Other products or services focus on either tracking who may not be hand sanitizing at every possible opportunity as tasks are completed near the patient/operative fields (e.g., line care or hand sanitizer devices that are attached to individuals that make it convenient to use and also provide tracking reports).

Despite what is going on in our healthcare environments inclusion of value analysis processes in critical decision making may make the difference in healthcare patient safety outcomes.

Barbara Strain, AM, SM(ASCP), CVAHP is a founding member and strategic board liaison for the Association of Healthcare Value Analysis Professionals (AHVAP).

References:
1. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/8197F323F4840D233A0C62F4726287E1/S0899823X21003627a.pdf/the-impact-of-coronavirus-disease-2019-covid-19-on-healthcare-associated-infections-in-2020-a-summary-of-data-reported-to-the-national-healthcare-safety-network.pdf
2. New Eng J Med. Increase Infections 2022.pdf
3. CMS. ECE
4. http://www.ihi.org/resources/Pages/Changes/ChangestoPreventSurgicalSiteInfection.aspx
5. https://www.cdc.gov/nhsn/pdfs/training/2019/ssi-508.pdf
6. http://patientsafety.pa.gov/ADVISORIES/Pages/201706_71.aspx
7. https://www.infectioncontrolresults.com/sterile-processing-changes

 

 

Value Analysis in the Pandemic Rear View Mirror: Looking Forward with IP&C and Risk Mitigation in Mind

Editor's note: This column originally appeared in the December 2021 issue of Healthcare Hygiene magazine.

Barbara Strain, founding member and strategic board liaison of the Association of Healthcare Value Analysis Professionals (AHVAP) caught up with Sue Miller, RN, MN, CMRP, CVAHP, to discuss lessons learned from the COVID-19 pandemic with a slant toward infection prevention and control (IP&C). Miller is past president of AHVAP, as well as senior director of enterprise value analysis for Thomas Jefferson University and Jefferson Health.

Barbara Strain (BS): As we look back on the past two years what role did IP&C play in decision making?
Sue Miller (SG): IP&C has been an integral part of Jefferson’s Value Analysis program since our enterprise-wide VA committees were implemented in 2018. Prior to 2020, an IP&C practitioner was assigned to each of our value analysis subcommittees to provide input to the value analysis committee decision-making and to enhance communication both at a local practice level and with other IP&C practitioners across the enterprise. To a general extent this is how IP&C primarily interacts with value analysis on an initiative-by-initiative basis where it seems practical (e.g., PPE apparel, masks, disinfectants, and medical products such as Foley catheters and central lines).
The experience of 2020-21 put value analysis, supply chain and IP&C in the spotlight. In certain key categories, time was not spent qualifying a variety of exam gloves, for example but what were the handful of key characteristics or specifications required for safety versus our ability to actually purchase and receive the goods. Roles shifted to vetting products and navigating feedback from known and unknown manufacturers, distributors, and brokers in real time while the crises unfolded all around them. IP&C assisted in monitoring the FDA Emergency Use Authorizations for products, antigen and antibody testing as well as CDC guidelines on isolation, quarantine, patient-care practice, and Environmental Protection Agency (EPA) disinfectant approvals and advising real-time consultation to ensure staff and patient safety.

BS: How has IP&C transitioned at the executive level at Jefferson Health in 2021?
SM: Value Analysis at Jefferson Health operates as an Enterprise System Executive Steering Committee process and structure, with four enterprise-wide value analysis subcommittees addressing specific clinical areas, such as perioperative services, med-surg commodities and devices, etc. Early in 2021 the organization created the role of enterprise vice president of infection prevention. One of the divisional IPs had be acting in an enterprise advisement role during the pandemic and stepped into the newly created VP role. Value analysis is collaborating with the VP and interpretating the different ways that individual’s contribution to achieving the overall enterprise goals for improving quality and attaining overall value. IP&C thought processes can be anticipated to assist in influencing categories at an enterprise level – home health, telehealth, capital acquisitions, construction planning and materials selection, M&A initiatives, as well as standardization, utilization, and the paving the road value-based care to based care design. This high-level decision making will enhance line of site divisional decision making.

BS: What is the one key critical skill that made the biggest difference during the pandemic and how will it live on post 2021?
SM: Effective communication at the highest level cannot be overrated. A simple example is how to message that there is an opportunity to review a category of product. Like most value analysis professionals, we have had to look for temporary product substitutes due to supply chain disruptions and at times there is a long lead time to getting back to where we need to be with our primary supplier. As an example, in one category, we introduced the concept of what would it look like if we approached this situation as an opportunity to change products to an alternate supplier. This notion made it through the divisions and back to the VP of IP before they had a chance to weigh in making it an awkward if not a potential trust breaking situation. Communication, planning and effective messaging is key!
Additionally, it has been imperative for us to develop a consistent supply interruption management process engaging strategic sourcing, value analysis, procurement and supply chain operations. We hold daily check-in meetings that began in 2020 and which we plan to continue into early 2022 to review back orders, on hand products, substitute products, demand, where we could shift from our enterprise divisions and keep a pulse on operations. The plan is to hardwire this process and pass on the learnings to the divisional level to develop a cadence that makes sense (once or twice a week). It engages everyone in effective communication regardless of the size of the organization.

BS: Keeping the patient at the center of decision making is essential to keep at the center of healthcare delivery. How is Jefferson health assuring this in the face of continued supply chain disruptions?
SM: In light of the need to vet so many alternate products, the needs of our patients and healthcare worker safety and the continual education required by these disruptions we focused the conversation with our medical community around mitigating risk. The four key inputs of risk mitigation are value analysis, clinical integration, strategic sourcing, and logistics. The consistent and open collaboration between the clinical community and the supply chain community has been vital to keep risk in check. We believe so strongly in this approach that the enterprise vice president of infection prevention as well as the enterprise medical director of risk management have both been added to the Enterprise Value Analysis Steering Committee.

BS: Back orders in a variety of healthcare product categories persist and according to some predictions this may last well into 2022. 1 Jefferson Health will be expanding its delivery of care in 2022; how do you foresee this unfolding?
SM: We have used our various divisions within our enterprise to create an internal source of goods. For example, if one division has specific products on hand that others need, we can take advantage of that. By effectively applying our learnings, growth can continue to support those efforts. We have been systematically creating a strong foundation for a resilient future through our enterprise thought leadership while setting a bar of standards to not only meet but to exceed our medical community needs.

Reference:
1. https://www.axios.com/health-care-plagued-by-new-supply-chain-shortages-4366675c-a984-483d-8996-ce70cf8b3656.html:

Healthcare Value Analysis Basics Provide the Grounds for Successfully Navigating the Path and Avoiding Pitfalls

By Mary E. Potter, RN, BS, CVAHP

This column originally appeared in the November 2021 issue of Healthcare Hygiene magazine.

As healthcare value analysis becomes more integral to balancing patient outcomes and financial viability, the need for a standard process for identifying products and services that will meet, but not exceed the requirements is greater than ever. Adhering to the basic principles of healthcare value analysis can help you avoid the pitfalls of product selection.

Pitfall 1: We have a process, but it is not always followed.
When you are experiencing non-compliance to the process, review the basics, have you established a Charter, is there a policy in place, have you created and clearly communicated the expectations to your leaders? More importantly, do you have the support of your executive team? Can you rely on them to remove barriers and support your decisions? Is your process patient centered? Clinicians are more likely to support initiatives that take into consideration the impact on the patient: the product quality, safety, and the impact on patient experience. Take time to make sure everyone is on board.

Pitfall 2: How do we know whether we should move forward with a product evaluation?
This question is all about methodology. A selling point for new products is often the claim that it will “reduce infections.” In the operating room (OR) setting the claim may be that use of the product will “save time.”
To decide whether to approve or reject moving forward with a request, the first step is to identify the need/opportunity. What do you need to achieve that you aren’t able to achieve now? If the claim is reduced infections, meet with your infection preventionist to learn what your current rates are. Do reports support there is an opportunity for improvement? Have you incurred Centers for Medicare & Medicaid Services (CMS) penalties for healthcare-acquired Infections (HAIs)? Your finance representative can help answer this question.
Is there an opportunity to reduce variations in outcomes and reduce costs through standardization and improved contract compliance?
If the claim is to “save time” meet with the subject matter experts (SMEs) to determine whether this objective is realistic. How do your procedural times compare with current industry standards or with you industry peers? Will reducing time result in decreased full-time employees (FTEs) or make scheduling of additional procedures possible?
If the proposed product does not satisfy a legitimate need, do not move forward with the request.

Pitfall 3: How will we know whether a product is acceptable? Should we use a rating system?
Once you determine the need is legitimate, before moving forward, establish the “measurable value.”
SMEs will compile a list of the requirements and characteristics the product/equipment/service must have to be deemed acceptable and identify the measureable value. Is there randomized, controlled, peer reviewed studies supporting improved patient outcomes, improved safety, or cost reduction?
Establishing valid evidence and identifying the product requirements provides you with the tool to evaluate one product or several competitive products. Rating systems often inject preference and subjectivity into the decision process. If you plan to use a rating system there must be clearly defined levels of achievement or acceptability. In place of a rating system, you might choose to simply evaluate each requirement with a “yes” the product satisfies the identified requirement(s) or “no” the product does not satisfy the stated requirement(s). If a product does not satisfy the identified requirements, reject it.

Pitfall 4: What if there is a suspected COI (conflict of interest)?
The Patient Protection and Affordable Care Act of 2010 requires drug, device, and biologic companies to publicly report nearly all gifts or payments they make to physicians beginning in 2013. Beginning on Jan. 1, 2021, reporting entities are now required to collect data about payments made to physicians and teaching hospitals as well physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and anesthesiologist assistants, and certified nurse-midwives. This information is available on the CMS website (https://www.cms.gov/OpenPayments).
Review all randomized, controlled, peer reviewed studies for COI disclosure(s) by the author(s).
Know your organization’s policies to insure you adhere to organizational compliance guidelines, comply with disclosure and confidentiality policies, and can serve as a resource for internal and external customers.

Pitfall 5: When is a trial necessary?
Trusting you have established the need for the proposed products and the product requirements, if there is no randomized controlled, peer-reviewed studies to support the efficacy of the product, you may need to conduct a trial to verify efficacy. A trial is most often requested for a new product/device/pharmaceutical for which there is little or no published information. The identified need and the product requirements and anticipated measurable value will provide the criteria on which you will evaluate the efficacy. Before proceeding with a trial, meet with SMEs to determine either the length of the trial or the number of uses necessary for an adequate determination of efficacy.
Information about existing products currently in use at organizations within your GPO, health system or at regional organizations may provide sufficient evidence of targeted efficacy, safety and patient outcomes in lieu of a trial.

Pitfall 6: What if we are not achieving the measurable value we projected for the approved product/device/pharmaceutical?
Following implementation, it is critically important to ensure you are achieving the measurable value identified. Follow up at three months, six months, one year and annually thereafter to verify you are achieving the projected outcomes. If not, why not? Has old product been removed from inventory? Is additional education required? Determine the root cause and work with SMEs to remedy the situation.

Taking time to apply the discipline of healthcare value analysis can help you and your team avoid these pitfalls. Once you realize the identified value, recognize the contributions made by team members and communicate and celebrate your success.

Mary E. Potter, RN, BS, CVAHP, is an independent value analysis consultant.

 

 

The Role of Value Analysis in Antibiotic Stewardship

By Barbara Strain, MA, SM(ASCP), CVAHP

This column originally appeared in the October 2021 issue of Healthcare Hygiene magazine.

In 2014 the Centers for Disease Control and Prevention (CDC) called upon U.S. hospitals to implement antibiotic stewardship programs using the Core Elements of Hospital Antibiotic Stewardship Programs1 which was subsequently updated in 2019. The seven core elements also form the foundation for antibiotic stewardship accreditation standards from The Joint Commission and DNV-GL. All leaders, physicians, clinicians, and staff working in healthcare settings should be aware of their organization’s antibiotic stewardship efforts and understand the part they can play in supporting these programs.
Hospital antibiotic stewardship programs (ASP) can increase infection cure rates while reducing:
· Treatment failures
· C. difficile infections
· Adverse effects
· Antibiotic resistance
· Hospital costs and lengths of stay

The key stakeholder groups mentioned in the core elements range from hospital epidemiologists, infection prevention and control (IP&C), infectious diseases and other physicians, pharmacists, quality officers and other leaders. Value analysis, although not mentioned in the seven core elements, could be the eighth element.
Value analysis programs are commonly structured into one or more teams of subject matter experts (SMEs) who review current products and services to assure they continue to provide total value to the organization in meeting its clinical and financial goals as well as use proven processes to review new technologies and devices, information technology-based services – such as sensor-based monitoring, artificial intelligence (AI), telehealth and out-of-hospital based solutions.
In 2016 the Centers for Medicare and Medicaid Services (CMS) re-introduced the Conditions of Participation to reflect current standards of practice and to support improvements in quality of care2 by:
· Reducing readmissions
· Reducing barriers to care
· Reducing the incidence of hospital-acquired conditions (including healthcare-associated infections)
· Improving the use of antibiotics (including the potential for reduced antibiotic resistance)
· Addressing workforce shortage issues
· Improving patient protections

The “conditions” significantly changed the landscape of new medical device review that continues today. Suppliers now market new products, equipment and services solutions to value analysis and SMEs primarily using clinical-based evidence to back up claims of reducing HAIs and/or HACs, improving quality, reducing readmissions, and decreasing emergency department visits while assisting hospitals in meeting their antibiotic stewardship goals.

To put these scenarios into perspective some examples include but not limited to medical devices that will prevent the acquisition of infections or assist in treating them effectively without long courses of antibiotics such as:
· Antibiotic or metal impregnated/coated central line catheters, urinary catheters, dressings, stents, bone cement, bed linens, cubical curtains
· Microbiology culture specimen collection devices
· Rapid bacterial identification and antibiotic testing methodologies
· Patient bathing with pH balanced cleansing agents
· Healthcare workers, others alcohol-based hand sanitizers
· Software-based solutions, such as assist in reducing surgical site infections by improving hand hygiene
· Other products and technology

The underlying theme is to prevent HAIs which leads to controlling the use of antibiotics.

No doubt you have seen the cargo ships anchored off the coastal harbors of California and New York waiting to dock and unload countless goods and food. The current wait for a dock spot is two and a half weeks. From there the cargo goes to warehouses where the loads are sorted and sent to their destinations. At that point it maybe a month or two or three before medical supplies reach your care environment. What happens in those in-between-times are backorders. To add to these conditions are the discontinuation of products by suppliers due to a variety of issues from lack of raw materials, low usage, switch of manufacturing lines to other COVID-related needs and business reasons.

To overcome daily needs to assure patients are cared for value analysis professionals work with SMEs and supply chain to identify suitable substitutes meeting key functional criteria, sometimes lining up two or more substitutes depending on availability. Value analysis keeps a watchful eye on the key characteristics of the originally approved product but that is not always realistic. One value analysis director stated that the antibiotic-coated catheter they had standardized to was discontinued; however, the manufacturer offered another one using a different antibiotic. This could create short- and long-term effects on acquiring/treating central line-associated bloodstream infections (CLABSIs) and potentially imbalance an organizations antibiotic stewardship in this one goal.

A paper in JAMA3 reported that of the 1,566 patients that met the study criteria during a six-month period in 2015 showed 55.9 percent of unsupported treatment with antibiotics for the conditions selected. In 2015, the study’s baseline year, only 150 hospitals submitted data to the National Healthcare Safety Network (NHSN), compared to more than 2,000 in 2019 with 49 states performing better on at least two infection types.4

A New Jersey hospital identified a new challenge related to the protocols in settings where patients are being treated for COVID-19.5 The article reported a cluster of 34 hospital-acquired carbapenem-resistant Acinetobacter baumannii (CRAB) cases during a surge in COVID-19 hospitalizations. This investigation highlighted the potential that this multidrug-resistant organism (MDRO) incidence peaked when there was a convergence of shortages in staff, personal protective equipment (PPE) and equipment that prevented standard practices from being followed. The researchers reported that once conventional IP&C strategies were reinstated, the CRAB rate returned to pre-COVID-19 incidence of fewer than two cases per month.

The link between products, equipment, and practice compliance especially during disruptive periods can have an impact on infection prevention and control as well as antibiotic stewardship efforts.

Barbara Strain, MA, SM(ASCP), CVAHP, is an independent healthcare value consultant whose clients range from new emerging and disruptive technology to Fortune 500 companies. Strain honed her expertise over a 40-year career as a healthcare provider across multiple specialties first in clinical laboratory operations, microbiology, disinfection and sterilization, and infection control, then as a value analysis professional. She is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP).

References:
1. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf
2. https://www.cms.gov/newsroom/fact-sheets/cms-issues-proposed-rule-prohibits-discrimination-reduces-hospital-acquired-conditions-and-promotes
3. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2777635
4. https://www.cdc.gov/hai/pdfs/progress-report/2018-Progress-Report-Executive-Summary-H.pdf
5. https://www.cdc.gov/mmwr/volumes/69/wr/mm6948e1.htm

 

 

 

 

Healthcare Value Analysis Professionals at the Infection Prevention Table

By Karen Niven, MS, BSN, RN, CVAHP

Editor's note: This column originally appeared in the September 2021 issue of Healthcare Hygiene magazine.

If we have learned nothing else in the last 18 months amid the pandemic, we have learned the importance of a strong value analysis process that supports our clinical teams, our financial teams, our operational teams, and our leadership teams. Healthcare supply chain has been challenged in 2020-2021 like no other time previously. We must use these painful learnings and events to embrace a value analysis process that is embedded in our organizations. The value analysis process then becomes “the way we do things” instead of “the things we do.” To be best prepared for our next challenges -- and there will be a “next challenge” -- we need to use our learnings and this time to elevate value analysis in our healthcare organizations to have a seat at these table. Value analysis professionals must be at the table -- at the clinical table, at the operational table, at the financial table, at the leadership table, and even at the infection prevention table. So, what does it mean to be at these different tables?

Being at the clinical table means as the clinicians consider the products to provide care for all patients, they use the evidence based clinical value analysis process as a part of their decision. Defined by the Association of Healthcare Value Analysis Professionals (AHVAP), this a “process for evaluating healthcare services for clinical quality and cost effectiveness.” This includes the review and evaluation of clinical evidence as these decisions are under consideration. Value analysis has been described as, “a transforming methodology in healthcare that helps providers select products and services, not on personal preference, but on the best value it brings to the organization and its patients.”

What higher purpose than this do clinicians have to their patients and the care they provide?

Being at the operational table means the involvement of all levels of practitioners, including physicians. This involvement is especially important in the evaluation of new technology and can drive unparalleled value to the new technology assessment. In organizations where physician led value analysis is in place, many of the preference products, such as surgical mesh or surgical energy, can be objectively reviewed and decisions made that supports clinical quality and cost effectiveness. These value analysis discussions are paramount in today’s environment and contributed to outcome excellence and cost containment.

What higher purpose than this do operational leader have to their organizations?
Being at the financial table means the value analysis professional is included in the financial decisions made by the organization. This would include both planning and executing the organization’s financial budgets and plans. A senior leader in my organization said, “We need to evaluate the cost of the care and not dwell on the price of the product.” And what better professional to support the financial teams in that evaluation than the organizations value analysis professionals?

What higher purpose that this do financial leaders have to their organizations and patients?
Being at the leadership table means that in addition to the other organizational leaders, value analysis professionals having a seat at the table allows them to contribute their expertise in conjunction with the AHVAP Value Analysis Statement of Purpose: “Healthcare value analysis contributes to optimal patient outcomes through an evidenced-based systematic approach to review healthcare products, equipment, technology and services. Using recognized practices, organizational resources collaborate to evaluate clinical efficacy, appropriate use and safety for the greatest financial value.”©

What higher purpose than this do leaders have to their organizations and patients?
Being at the infection prevention table means the value analysis professional works with their infection prevention and control professional when evaluating products and make appropriate selection decisions based on sound infection prevention and control (IP&C) guidelines. As a previous surgical services director, I have had the invaluable experience of being included in discussion with IP&C professionals and had the opportunity to invite other perioperative staff as well. In the surgical services practice arena, many times the most valuable voice is the voice of the team in the room. They are the voice of patients who may be unable to speak for themselves. These team members know how to provide the best quality care behind the operating room (OR) door. And this is the voice we need in the value analysis discussions and decisions.

We also must embrace the entire perioperative patient care continuum, including pre-op, intra-op and post-op for patient normothermia. To accomplish this quality patient outcome, our value analysis team should have those patient care areas included in these discussions. As we work across this continuum on the perioperative infection prevention, we need to have full team decisions on the following and explore a value analysis strategy including:
• Analyze current products related to SSI
• Infection prevention/quality working with supply chain to align on product decisions
• Opportunity to combine products for increased value
• Risk share contract solution availability to warrantee prevention

What higher purpose that this do infection prevention leaders have to their organizations and patients?
As the Hippocratic Oath states, “first do no harm.” What a life-changing opportunity value analysis professionals have at this pivotal time in the delivery of quality healthcare. The opportunity to be part of the development, delivery and healthcare changing value analysis process. You have the opportunity to be a part of this journey. So, join value analysis professionals on this amazing industry changing ride.

Karen Niven, MS, BSN, RN, CVAHP, is the Southeast Region director for AHVAP as well as director of Performance Groups for Premier Healthcare Alliance.

Value Analysis Partnership and the Approach With Surgical Services Disruption

By Karen Tucker, MSN, RN, NEA-BC; Gloria Graham DNP, RN, CVAHP; and Heather Waters, MSN, RN

Editor's note: This column originally appeared in the August 2021 issue of Healthcare Hygiene magazine.

Healthcare is recognized for patient care and the outcomes provided by professionals to ensure safe and positive outcomes. To support and maintain positive outcomes for patients and staff, the right supplies and equipment must be available at the right time for the right patient. This area of supply and equipment known as supply chain management/value analysis, is not top-of-mind to caregivers as a potential threat to patient care or daily operations. The lack of equipment or supplies has an impact on operations by delaying care, patient safety, patient outcomes, and ultimately can create waste and harm in the system (Kritchanchai, et al., 2019). Mitigating the risk of patient care disruption is achieved through collaboration with supply chain and value analysis. The Association of Healthcare Value Analysis Professionals (AHVAP) recognizes value analysis as the process that evaluates products to improve patient outcomes through an evidence-based approach while also assessing safety, efficiency and the financial impact.

Collaboration Through the Pandemic
With the last year, healthcare systems and staff recognized how critical the need for equipment and supplies are. Impact of the pandemic and the supply strain highlighted the need to partner with frontline staff, supply chain and value analysis (VA). A basic understanding of this work and collaboration is key to connect the importance to patients and staff. Access and availability to appropriate supplies and equipment for patient care improves workflow and work satisfaction for staff and better outcomes for the patient. Supply chain’s focus in healthcare is to provide appropriate equipment or supply to the patient or staff without causing disruption, or harm to the patient (Emmett, 2019). The need for supplies can be something as simple as gloves and gowns or a critical piece of medical equipment to sustain life for a patient. All supplies within a healthcare system require the right key stakeholders to ensure the process is efficient and the correct supplies are in place from a practice and safety perspective.

Interdisciplinary Approach with Disruption in Supply
A disruption in the supply or equipment process can have negative outcomes. Frontline staff expectations are to have access to supplies and equipment when needed, yet most lack understanding or appreciation of value analysis/supply chain processes. During the COVID-19 pandemic, healthcare systems were faced with a pace of high demand for supplies and equipment coupled with production issues. As a result, hospital leaders and frontline staff quickly realized the importance of supply chain and value analysis impacts and disruptions to staff and patients based on this critical service.

Through the support of VA staff, staff was able to quickly assess and evaluate the needs, assess new products as alternates in conjunction with being mindful of the financial impact. Organizations without a strong VA structure and coordinated team likely experienced even more challenges and struggles to work through as they established contingency plans and set staff at ease with the plans.

Operational Impact
Throughout the last year, the disruption of supplies and equipment was felt by the frontline. All patient care areas were monitored and assessed on an ongoing basis for impact. Some areas of focus during this time were personal protective equipment (PPE) allocations, decrease in volume of specialty supplies, and basic inventory of items causing modification of standard work.

VA staff collaborated with surgical services with PPE allocations due to low inventory during the COVID-19 pandemic for the following items:
• Gowns: Determining the correct level gown and style for wear
• Gloves: Finding alternative manufacturers for the different surgeon needs
• Shoe Covers: Finding the right floor grip/non-slip, universal size and fabric for wear
• Bouffant/skull caps: Finding the correct thickness and size to meet a universal acceptance

As manufacturers attempted to maintain inventory for high-use products, it came with a price to other lower-volume products such as pediatric specialty items. This disruption ultimately led to discontinued items, where the VA staff worked to find alternative items that were presented to the surgical teams. This process was multidisciplinary with VA staff and key stakeholders of the surgical services teams reviewing the product, cost, and outcomes of the alternate product. At times due to patient or special design needs, supplies and alternatives were not available, which created the need for a practice modification provided by the clinicians. Some of these items included:
• Urinary stents
• Cath Lab Quick Fill Straw
• Stapler
• Miscellaneous catheters

The daily perioperative maintenance was also affected during this time, creating taskforce assistance to plan and modify a standardized work process.
• Large sharps containers were added in as a pandemic/critical item
• Disinfectants—weekly par and recycling of containers due to low inventory

There is a value and appreciation for value analysis to work in partnership with frontline operational teams as a critical voice. Through partnering with frontline leaders, both medical and nursing, and other key stakeholders, VA professionals are able to make the best decision for alternate supplies. Any resulting practice changes are decided by the interdisciplinary team, ensuring that any changes are evaluated keeping patient and employee outcomes the priority.

Karen Tucker MSN, RN, NEA-BC, is assistant vice president at Cincinnati Children’s Hospital Medical Center.

Gloria Graham DNP, RN, CVAHP, is a clinical value analyst at Cincinnati Children’s Hospital Medical Center.

Heather Waters MSN, RN, is a clinical value analyst at Cincinnati Children’s Hospital Medical Center.

References:
Emmett D. (2019) Supply chains in healthcare organizations: Lessons learned from recent shortages. Hospital Topics. 97(4), 133-138.

Kritchanchai D, Krichanchai S, Hoeur S and Tan A. (2019) Healthcare supply chain management: Macro and micro perspectives. Log Forum, 15(4), 531-544.

Healthcare Textiles, Laundry and Infection Prevention Programs in Ambulatory Care

By Melanie Miller, RN, CVAHP

Editor's note: This column originally appeared in the July 2021 issue of Healthcare Hygiene magazine.

The recent pandemic begged the question, “Are we doing enough to manage ambulatory care textiles?” Ambulatory surgery centers (ASCs), like healthcare organizations, contract with laundry processors. Laundry processors are expected to follow “hygienically clean” linen standards compliant with the Association of Linen Management (ALM) and TRSA. Additionally, the Association for Professionals in Infection Control and Epidemiology (APIC), has developed standards for ensuring that laundry processors comply with stated recommendations for collecting, transporting, sorting, washing, drying, staging and return delivery to the user.

The pandemic opened up Pandora’s box and the world was suddenly introduced to the concept of disposable and reusable personal protective equipment (PPE) during daily news briefings. Within a few days, the public was notified by news media that PPE and medical commodities were in short supply across the country due to lack of basic raw products and dramatic COVID-19 shutdowns internationally.

Laundry processors were negatively affected by the worldwide pandemic, as were HCOs and service industry businesses alike. When restaurants and service providers were placed on hiatus, laundry processors in both the healthcare and service industries experienced immediate loss of business and revenue. This loss resulted in downstream impacts including, but not limited to, personnel layoffs and laundry closures and shutdowns. If a laundry processor was fortunate to have both service and healthcare organization clientele, it fared better during the pandemic.

Understanding the operational challenges and reusable/disposable product shortfalls throughout the pandemic is important as we begin to dissect infection prevention programs related to textile management in the ambulatory care setting.

Many ASCs were shuttered during the pandemic due to the “hold” on elective procedures. It is estimated that ambulatory centers lost 60 percent of patient throughput at the height of the pandemic.

For those ASCs that remained open, ambulatory service leaders learned quickly that remaining nimble and mid-course correcting when confronted with lack of disposable PPE was key to staying afloat. Leaders quickly contacted their supply chain, purchasing and value analysis colleagues to help them source appropriate reusable PPE.

This was not an easy task. For years, reusable PPE was talked about as a substantive alternative to waste, reducing our carbon footprint and improved sustainability but HCOs were not sold. Fast-forward to disposable shortfalls and drastically reduced allocations without notice. Immediately reusable suppliers went into overdrive trying to produce reusable PPE to meet the new and growing need.

The challenge was which standards were to be followed and would the reusable PPE meet the current published standards. Additionally, would the PPE pass the hygienically clean requirements, including wash cycle validation and certification by recognized testing industry leaders.

Again, ambulatory care leaders looked to supply chain, specifically, value analysis leadership to determine best practice and the required testing and certification to ensure that reusable PPE met and exceeded ANSI/AAMI and Centers for Disease Control and Prevention (CDC) guidelines, including AATCC 42/127, Class I Flammability, Anti-Static and Wash Cycle certification.

Value analysis committees across the country had a new direction sourcing gloves, masks, gowns, respirators, ventilators, and other critical life-saving equipment not in that order. Whereas in the past, a product review might take four to six months, aligning with project management guidelines, communication and collaboration, addressing value analysis methodology, maintaining best business and professional, ethical, and financial practices there simply was not enough time.
At the same time, gray market brokers capitalized on the challenging state of events and went to market with products that did not meet minimum performance standards.

The world of inpatient and ambulatory care was turned upside down in some counties and states due to lack of disposable and reusable supplies, including sheets, towels, patient gowns, isolation gowns and laundry bags.

Leading healthcare laundry and textile organizations jumped to attention and developed webinars and information sharing blogs to help educate HCO staff and healthcare apparel manufacturers. Laundry processors realized that however bleak, downtime was a blessing and instituted new and improved facility cleaning standards, equipment preventive maintenance review and safety training for all staff with an eye to minimizing employee exposure and risk in the workplace.

APIC, through its regional and national leadership forums, helped educate healthcare epidemiologists and value analysis professionals about the most up-to-date standards for disposable and reusable textile management, including PPE and isolation gowns.

When the critical pandemic situation improved, states slowly began reopening. Laundry processors across the country breathed a sigh of relief. They could reestablish their processes and ensure hygienically clean compliance. Many of the laundry processors used the downtime to review their operational policies and procedures to ensure compliance with state directed healthcare textile standards.

Laundry processors knew that going forward their key to future success was engaging the healthcare organizational leaders in inpatient or ambulatory settings to showcase their operational improvements that would result in improved throughput and service post pandemic.

Taking a fresh look at relationship building, many laundry processors leaders reached out to APIC, the Society for Healthcare Epidemiology of America (SHEA) and hospital leaders, and through virtual and in-person teams, reviewed policies and procedures to ensure that the local laundry processors were compliant with hygienically clean standards. Laundry processing leadership recognized the benefits of weekly, monthly, and quarterly check-in with their inpatient and ambulatory clientele.

Reviewing laundry assessment tools resulted in streamlining internal processes and illuminating the partnering benefits with key leaders in linen, value analysis and infection prevention and control (IP&C) in the inpatient and ambulatory setting.
Going forward, a hybrid model appears to be a thoughtful, planful approach to manage ambulatory textiles. Developing service guidelines that encourage patients to wear appropriate clothing to outpatient appointments, imaging procedures and surgical procedures minimizes the need for disposable or reusable linen.

Ambulatory care teams can focus on reusable and disposable textile patient needs that ensure patient dignity, comfort, and best experience. A refreshed approach to ambulatory textile oversight will help manage cost, reduce textile handling, eliminate waste, align with IP&C protocols, and contribute to overall sustainability programs encouraged by healthcare leaders.

Melanie Miller, RN, CVAHP, is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP), and vice president/chief strategy officer of Silver Lining Apparel.

 

 

Infection Prevention and Value Analysis Forge Even Stronger Relationships

By Barbara Strain, MA, CVAHP

Editor's note: This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

Prior to 2020 the participation of infection prevention and control (IP&C) was a key element of successful value analysis (VA) initiatives, but the role took on even more significance because of the COVID-19 pandemic.1 SARS-CoV-2 was a novel virus in the most complete sense. It had not been previously isolated, its mode of transmission was not completely understood, nor were there laboratory tests to detect the presence of the virus itself nor testing for antibody levels to determine immune status. Hot spots were occurring with the rapid surge of symptomatic, sick, and dying patients in healthcare institutions around the world. It became obvious very quickly that there were competing challenges that effected all aspects of the path forward: staff safety, vetting, sourcing, and conserving supplies, and patient care.

To quote an IDN that was interviewed for an Association of Healthcare Value Analysis Professionals (AHVAP) podcast in May 2020, “ensuring the safety of the front-line staff” was essential. To stay abreast of the fast-changing CDC guidelines to assure the most appropriate personal protective equipment (PPE) was available to the clinical and support staff, infection preventionists (IPs) conducted real-time assessments of how care was being provided. It was quickly determined that the usual method of triage and assigning patients to open ICU beds was not an optimal model, so IP&C recommended cohorting patients and staff to dedicated ICUs as the best scenario.

In this newly created, dynamic care environment, staff could don gowns, masks and head coverings, and wear them for longer periods of time without removing, and, in some situations, donned coveralls over basic PPE to conserve use.

Each decision was made based on communication with value analysis professionals (VAPs) who are the clinical connection to hospital supply chain (SC) operations. Before practice was changed or procedures edited, IPs and VAPs conferred on availability of supplies to ensure that new plans could be carried out. SC would provide timely “run rates” indicating how fast high-demand supplies were being used and forecast how long current stock of supplies would last as well as when additional stock would arrive. Using their knowledge, skills, and abilities IPs and VAPs created lists of the key characteristics of the high-demand supplies which reduced the time to locate best-fit equivalents to ensure uninterrupted care.

When it became clear that the global supply of non-powered respirators/N95 masks were not keeping up with demand and were met with fit-testing constraints, the CDC decided to allow either third-party vendors to provide reprocessing services of these masks or allow hospitals to perform reprocessing on site by specific approved methodologies. VAPs gathered the information to determine which option(s) had the shortest implementation timeline for teams led by IPs along with staff from biomedical engineering and facilities, and executive leadership could make easy-to-operationalize, safe decisions.

Other conservation practices included IP&C approving the use of extra-long IV-intravenous tubing connected to the patient to allow respective IV pumps to function outside the room. This measure decreased the number of times a fully donned nurse had to go into a patient’s room to monitor and adjust the settings.

Even before it was confirmed by CDC and NIH that patients were highly contagious, IPs, chief medical officers and chief nursing officers instituted negative-pressure room policies. With the assistance of facilities management professionals, plans were put in place to convert regular patient rooms, emergency department holding rooms, and other appropriate care-spaces into negative-pressure conditions where physically possible. This kept contagious viral particles from entering non-care areas or areas where non-healthcare workers or those not wearing powered or non-powered N95 masks were present.

Prior to the availability of certain drugs, convalescent serum or other treatments were available for patients whose lung capacity and breathing conditions deteriorated, a large percentage were put on ventilators.2 In most hospitals there are fleet of ventilators for a normal level of patient need, plus a reserve amount for unexpected circumstances -- but it is not equipped to handle the high, long-lasting surge caused by COVID-19. VAPs were called into action to vet a new set of criteria for ventilator tubing and hoses as well as connectors for their own fleets of ventilators and for other models that may have been rented or purchased. Some hospitals that had both a space constraint and ventilator shortage adapted what the FDA referred to as “multiplexing ventilator tubing connectors, also known as ventilator splitters, in situations in which no alternatives for invasive ventilatory support are available,” and provide a considerations list that health care providers and facilities should review.3

In extreme situations, patients were placed on ECMO-extracorporeal membrane oxygenation treatment, where oxygen is delivered directly to the patient’s bloodstream to bring relief to breathing impairment. Hospitals with specially trained staff and ECMO equipment to support such treatments put additional strain on capacity to use this practice as patient demand rose above normal. Ventilators and ECMO come with their own set of issues that IP&C monitored closely along with anesthesiology and respiratory therapy to assure that precautions were in place to prevent development of ventilator-associated pneumonia, bloodstream and other infections.

Since the number of COVID-19 cases have ceded to lower, manageable levels, hospitals have begun to open their care services to pre-2020 conditions. Lessons learned from the pandemic informed how the delivery of care can be effective through:
· Reviewing and updating emergency operations, infection prevention and control, and institutional & departmental policies,
· Creating a response handbook based on critical triggers which include but are not limited to:
- Monitor CDC, WHO and other global health watchdogs by Emergency Preparedness Committees and IP&C
- Establish a global raw materials, work-in-progress and finished goods alert system and report dashboard
- List key departments – such as IP&C, VAP, SC -- who should be notified based on mutually agreed upon on-hand and available-to-purchase product thresholds
· Identifying top product needs in incident categories and develop a list of key characteristics for each product to facilitate quick decision-making. For example, for air born contagion: non-powered or powered respirators, face shields, protective gowns, oxygen masks/tubing, list of key characteristics each product type
· Adopting the communication style and methods that worked during Covid19 as your organization’s everyday method.

The COVID-19 pandemic has taught us many lessons but the importance of interprofessional relationships has been undeniably one of the best learned.

Barbara Strain, MA, CVAHP, is an independent healthcare value consultant whose clients range from new emerging and disruptive technology to Fortune 500 companies. Strain honed her expertise over a 40-year career as a healthcare provider across multiple specialties first in clinical laboratory operations, microbiology, disinfection and sterilization, and infection control, then as a value analysis professional. She is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP).

References:
1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html#IPC-priorities
2. https://www.npr.org/sections/health-shots/2020/04/02/826105278/ventilators-are-no-panacea-for-critically-ill-covid-19-patients
3. https://www.fda.gov/medical-devices/letters-health-care-providers/using-ventilator-splitters-during-covid-19-pandemic-letter-health-care-providers